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' 1 <br /> APPLICATION FOR PERMIT " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED <br /> (Complete.in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is ' <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or Na- 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health Distriicct..- ,►. <br /> Job Address ` '� �` I� � City ! �(ot Size ty( PM <br /> 5 <br /> Owner's Name Address Phone <br /> Contractor... �AU� Address . C3t2 License No .'j Phone ��Tl <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL­AEPLACEMENT O DESTRUCTION ❑ <br /> PUMP INSTAL LAT�I ❑ �` SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE:TO.NEAREST:.`SEPTIC TANK SEWER-�L`1NES DISPOSAL F PROP. LINE <br /> { ' FOUNDATION f y ''AGRICU.LTURE WELL ER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL` PROBL AREA RUCTION SPECIFICATIONS <br /> Ll Industrial _0_O <br /> Operi BoT of m"'" ❑ Mantec Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pac ...... �"" � Type o_f Casing Specifications <br /> 17 Public n Other �❑ pelta Depth of Grout Seal Type of Grout <br /> 3 Irrigation =._Appr epth y`l".I Eastern rface Seal Installed by <br /> 4'Repair Work'DSr1E M----- 'y ' -Pu' p "P.` State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 ' <br /> Depth Filler Material Ieelow 50' <br /> TYPE,OF.SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION ESTRUCTION I I (No septicTsystem_permitted if public sewer is 6� <br /> 4-j-7,, . .r. ` 3 �� available within 200 feet.) h <br /> Installation will serve: Residence Commercial_ Other ? <br /> Number of living units: —A Number of bedrooms <br /> _ Character of s d id_a depth nf�3'feet?" -C%_�j -l7ifG Water table depth <br /> SEPTIC TANK rT�ipelMfg !!/�4 [MCLS/ Com' UC Capacity—A-26—pa No. Compartments <br /> PKG. TREATMENT PLT. ❑ z , Z / Method of Disposal _ <br /> �! istan a to nearest: Well -012 Foundation:' Property Line ZQ <br /> LEACHING LINE C.r No. &`Length of lines Total length/size q� <br /> Pesti, .. <br /> FILTER BED ❑ Distance-to`nearest: <br /> Well Foundation Property Line , <br /> SEEPAGE PITS 10 Depth" Size _ Number t 'F <br /> SUMPS ❑ Distance to nearest: Well Foundation Propeity Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Jbaquin Local Health Di§trict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting'signature <br /> certifies the following: "I cern that in the performance of the work for which this permit is issued,l shale employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant us call fo tl requir inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: L l <br /> FOR DEPARTMENT USE ONLY _ <br /> i <br /> Application Acceptedby Date Area <br /> Pit or Grout Inspection by Date `'^f Final Inspection by Date <br /> a- <br /> ❑ Stk -466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> "FEE AR4OUNT-DUE— —AM0UNT'REmiTTED" CK RECEIVED BY I DATE PERMIT'NO. <br /> INFO ` CASH �[] <br /> a,EH 13-24 IRE'.1 -d <br /> EH 14-28 } <br /> A <br />